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Program Details

ENDO PHARMACEUTICALS, INC.
Endo Patient Assistance Program for Frova

Frova 2.5mg (frovatriptan succinate)
 
CONTACT INFO
Address: PO Box 66761
St. Louis, MO 63166-6761
Phone: 1-866-824-4747 Provider Phone:
Fax: 1-800-889-0353 Website:
ELIGIBILITY
Eligibility Info:
  • Patient must meet specific income requirements and must not have prescription drug coverage from an insurance provider.
  • Income at or below: Single 200 % FPL
      Couple 200 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
      Credit for Dependents allowed
    Medical expenses can be deducted from reported income: No
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Prescription section on form acts as prescription.
    Physician License #
    Required:
    Either DEA or State
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Provider
    Quantity in Shipment: Up to 90-day supply
    Delivery Time: 2-4 weeks
    Re-application Policy: New application every 3 months
    New financial information every 12 months
    New prescription every 3 months
    Refill Policy: Contact program for refills
    Other Information:

    Last Updated: 04/28/2017

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.



     

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